Provider Demographics
NPI:1194190637
Name:VINCENT, KELLY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:VINCENT
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:8854 W EMERALD ST
Practice Address - Street 2:SUITE #102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4844
Practice Address - Country:US
Practice Address - Phone:208-323-4747
Practice Address - Fax:208-323-4848
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2023-04-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant